Treating Brain Aneurysms
Written by: Aaron Cohen-Gadol, MD
Last Updated: October 8, 2024
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A brain aneurysm refers to a balloon-like bulge caused by weakness in a segment of the brain's arteries. This condition affects approximately one in 50 Americans, which accounts for about 2% of the population. Currently, up to 6 million Americans are living with unruptured brain aneurysms. While not all brain aneurysms rupture, those that do can lead to significant disability and even death.
Fortunately, brain aneurysms are detectable and often treatable. Here is a comprehensive overview of the four standard treatment options available for brain aneurysms. Detailed information for each option can be found through the provided links.
Open Surgery for Brain Aneurysms
Open surgery is the most durable, long-lasting treatment option for brain aneurysms. It is an invasive technique usually recommended for large but easily accessed aneurysms. This involves making an incision in the scalp and drilling through the skull to access the affected blood vessels. The surgeon then applies one of the following techniques to eliminate the aneurysm:
Occlusion Technique: Clipping
The occlusion technique involves placing a specialized metal clip around the aneurysm neck, effectively halting blood flow to the aneurysm. This is the most common open surgery technique for treating brain aneurysms.
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Bypass Technique
The bypass technique is usually reserved for rare situations and involves rerouting blood vessels around the aneurysm. This redirects blood through a different vessel pathway, preventing it from entering the aneurysm. This technique may be necessary for exceptionally large brain aneurysms when clipping is not effective.
Although rare, potential complications of open surgery for brain aneurysms include significant bleeding and stroke. While there is a possibility of an aneurysm recurring, meaning it may reform or enlarge over time, this occurrence is typically uncommon following a surgical clipping procedure. Recovery from surgery takes between 4 and 8 weeks for unruptured aneurysms, or longer for ruptured aneurysms.
Endovascular Treatment for Brain Aneurysms
Endovascular treatment is a less invasive technique for treating brain aneurysms. It involves insertion of a wire and catheter through a small incision on the arm or leg. The operator then guides the wire and catheter through the vascular system until it reaches the affected blood vessel in the brain. At that point, one or both of the following techniques may be used to treat the aneurysm:
Coiling
The coiling technique involves inserting metal wire coils into the aneurysm’s bulging sac. The coils cause the aneurysm to clot, cutting off blood supply to the sac — effectively removing it from circulation and thereby treating the aneurysm.
Figure 1: Coiling of an aneurysm (Credit: Yuriy Kulikov).
Stenting
The stenting technique involves using a special device called a flow diverter to cover the aneurysm’s opening. The stent diverts blood away from the aneurysm, effectively cutting it off from circulation.
Figure 2: Flow diverter stent for an aneurysm (Credit: Yuriy Kulikov)
The recommended endovascular technique depends on the aneurysm’s size, shape, and location. Endovascular procedures typically require a shorter recovery period than open surgery, but recurrence of the aneurysm can occur in nearly a quarter of aneurysms treated by this approach. This may necessitate additional endovascular or open surgical treatments.
Medical Management for Brain Aneurysms
Medical management of brain aneurysms involves administering medications to control other medical conditions, such as high blood pressure and high cholesterol. It is important to understand that these medications do not directly treat the aneurysm itself. Instead, they aim to prevent aneurysm formation and complications associated with the aneurysm, such as rupture. Medications cannot reverse aneurysm formation.
Medications that reduce cholesterol levels in the blood and manage high blood pressure play a crucial role in preventing aneurysm formation and rupture. Uncontrolled high blood pressure exerts excessive stress on the walls of blood vessels, making them more prone to developing weak spots for aneurysm formation. High blood pressure also can increase the chances of aneurysm rupture.
Observation for Brain Aneurysms
Observation for brain aneurysms is an alternative to surgical and medical treatment. While seemingly "doing nothing" may seem preposterous, in some cases, it may be a safer alternative to treatment. Observation is typically an option only for small and asymptomatic aneurysms that have not ruptured.
While most brain aneurysms do not produce symptoms and go undetected throughout the patient’s life, once discovered, they must not be ignored. Asymptomatic aneurysms are often diagnosed when a patient is undergoing exams for a different medical concern. When found, it is important to discuss the risk and benefits of treatment with a neurosurgeon.
Observation may be advised for small brain aneurysms that remain asymptomatic, or in cases where the potential risks associated with treatment outweigh the benefits of closely monitoring the condition over time. This approach involves undergoing periodic imaging tests to assess the aneurysm's size and shape.
Ideally, observation can continue if the aneurysm remains stable without significant growth or the development of concerning characteristics such as blebs. Blebs are small protrusions on the surface of an aneurysm that represent weak areas in the aneurysm wall and can increase the risk of rupture. If the aneurysm exhibits any worrisome changes in size or shape, the physician may recommend treatment.
The "watchful waiting" approach can bring about anxiety and stress. Remember that the choice to pursue treatment can be discussed with your medical team at any point. Observation may also serve as an interim measure, allowing time to address finances or to facilitate a more thorough decision-making process.
Key Takeaways
- Brain aneurysms are relatively common, and most are asymptomatic and usually go undetected.
- Symptomatic, bleeding, and ruptured brain aneurysms (and those likely to rupture) should be treated.
- Open surgery and endovascular surgery are the standard treatment options for brain aneurysms.
- Medical management can only prevent aneurysm formation and rupture to a certain extent.
- Physicians can also recommend observation for asymptomatic small aneurysms that do not pose an immediate risk.
